Citation Nr: 1443280 Decision Date: 09/26/14 Archive Date: 10/06/14 DOCKET NO. 09-21 315 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for headaches. 2. Entitlement to service connection for a low back disability. 3. Entitlement to service connection for a gastrointestinal disorder, to include gastritis. 4. Entitlement to service connection for carpal tunnel syndrome. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD H. Hoeft, Counsel INTRODUCTION The Veteran served on active duty from January 1969 to January 1971, and from January 1991 to May 1991, with additional service in the Army Reserve until 1995. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia, which denied the claims on appeal. The Veteran submitted a notice of disagreement in May 2008, a statement of the case was issued in June 2009, followed by a supplemental statement of the case in October 2009, and a substantive appeal (VA Form 9) was received in November 2009. In October 2012, the Veteran testified before the undersigned at a hearing at the RO. A transcript of this hearing is of record. This matter was previously before the Board in March 2013, at which time it was remanded for further development; subsequently, a January 2014 rating decision granted entitlement to service connection for bilateral hearing loss. This represents a full grant of benefits sought on appeal for this issue, and thus, entitlement to service connection for hearing loss is no longer in appellate status. The Board has reviewed the electronic records maintained in the Virtual VA and Veteran's Benefits Management System (VBMS) systems to ensure review of the totality of the evidence. FINDINGS OF FACT 1. The most competent and probative evidence of record demonstrates that a headache disorder did not have its clinical onset in service and is not otherwise related to any period of active duty and/or reserve service. 2. The most competent and probative evidence of record demonstrates that a low back disability did not have its clinical onset in service and is not otherwise related to any period of active duty and/or reserve service; arthritis of the lumbar spine was not exhibited within any first post service year. 3. The most competent and probative evidence of record demonstrates that a gastrointestinal disorder did not have its clinical onset in service and is not otherwise related to any period of active duty and/or reserve service. 4. The most competent and probative evidence of record demonstrates that carpal tunnel syndrome did not have its clinical onset in service and is not otherwise related to any period of active duty and/or reserve service. CONCLUSIONS OF LAW 1. The criteria for service connection for headaches have not been met. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 2. The criteria for service connection for a low back disability have not been met. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2013). 3. The criteria for service connection for a gastrointestinal disorder have not been met. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). 4. The criteria for service connection for bilateral carpal tunnel syndrome have not been met. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2013). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). A January 2008 pre-adjudication letter was issued to the Veteran with regard to his service connection claims. The letter notified the Veteran of what information and evidence is needed to substantiate his claims of service connection, the information and evidence that must be submitted by the claimant, the information and evidence that will be obtained by VA, and the information and evidence necessary to establish a disability rating and effective date in accordance with Dingess/Hartman. The Board finds that VA has fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of the Veteran's claims, to include substantial compliance with the March 2013 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Post-service VA and private treatment records have been obtained. The Veteran has provided numerous written statements in support of his claims. The claims file also contains a transcript of his hearing testimony from the October 2012 Board hearing. The Board notes that the Veteran's service treatment records from his period of active duty service in 1991 and service with the US Army Reserve are missing. The RO undertook extensive development in an attempt to locate these records, as instructed by the 2013 Remand. These records are evidently unavailable. Under such situations, the Board has a heightened obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). VA examinations were performed in January 2014 with respect to the issues decided in this appeal. 38 C.F.R. § 3.159(c) (4). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations and opinions obtained regarding a headaches, carpal tunnel syndrome, gastrointestinal disorders, and a low back disability are more than adequate, as they are predicated on a full reading of the private and VA medical records in the Veteran's claims file. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues decided herein has been met. 38 C.F.R. § 3.159(c) (4). Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claim. Legal Criteria - Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2013). In general, service connection requires competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, such as arthritis, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a); arthritis and/or degenerative disc disease are qualifying chronic diseases. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As a result, service connection via the demonstration of continuity of symptomatology is applicable in the present case. Service connection also may be granted for disability resulting from disease or injury incurred in or aggravated while performing active duty for training (ACDUTRA) or for injury incurred or aggravated while performing inactive duty training (INACDUTRA). 38 U.S.C.A. §§ 101(24), 106, 1131. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2013). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court of Appeals for Veterans Claims held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. Here, the Board briefly notes that service treatment records from the Veteran's second period of active duty service, and reserve service are unavailable for review. When a veteran's service medical records are not available, the Board's duty to explain its findings and conclusions is heightened. O'Hare v Derwinski, 1 Vet. App. 365, 367 (1991). The case law, however, does not establish a heightened "benefit of the doubt," but rather only a heightened duty of the Board to consider the applicability of the benefit of the doubt, to assist the claimant in developing the claim, and to explain its decision when the veteran's medical records have been destroyed. The legal standard for proving a claim for service connection is not lowered, but rather the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the appellant is increased. 1. Headaches The Veteran seeks service connection for headaches. He primarily contends that this disability stems from his initial period of active duty service (i.e., from 1969 to 1971). During his Board hearing before the undersigned, he testified that he was treated in-service for headaches and that he receives current treatment in the form of prescription medication for migraines. See, e.g., Hearing Transcript, p.22. At the outset, the Board acknowledges that that the Veteran's STRs from his brief period of active duty service in 1991, as well as STRs from his period of Reserve service (i.e., 1971 to 1995), have been sought, but are unavailable for review. See Formal Finding, September 2009; January 2014; see also PIES Responses, January 2008, and May 2013. The Board is aware of its heightened duty in this regard. See O'Hare, supra. As noted, however, the Veteran primarily contends that his headache disability had its onset during his first period of active duty service, from 1969 to 1971. See Hearing Transcript. At this juncture, the Board also wishes to make clear that, based on the Veteran's service personnel records (SPRs) and DD Form 214s, there is no evidence of record to suggest that the Veteran had service in the Republic of Vietnam, or in the Persian Gulf so as to avail himself of the provisions set forth under 38 C.F.R. §§ 3.309(e), or 3.317(a)(1)(i), respectively. Service treatment records from the Veteran's first period of active duty service reveal a single complaint of headaches, associated with stomach cramps, in February 1969. The December 1970 separation examination is silent for complaints, treatment, or diagnoses relating to headaches; clinical evaluation of the neurological system was normal; and the Veteran denied a history of frequent or severe headaches on his separation Report of Medical History. Following service, the first documented treatment of headaches is not shown until 2012. See Statement from Dr. D. Notably, in a February 2010 VA treatment record, he denied headaches. In October 2012, Dr. D., a private physician, submitted a letter indicating that the Veteran had complained of chronic pain over various parts of his body, including chronic headache, and that he had mentioned he served during Vietnam and participated in Desert Storm. Dr. D stated then went on to state, "It's a possibility that his health problems may be caused by some type of exposure during his line of duty." Here, the Board notes that Dr. D's opinion is far too speculative to be of any significant probative value to establish a causal relationship. See Warren v. Brown, 6 Vet. App. 4, 6 (1993) (holding that a statement expressed only in terms such as "could have been" would not create a reasonable possibility that the outcome would be changed); see also Obert v. Brown, 5 Vet. App. 30 (1993). Moreover, the opinion fails to identify the environmental "exposure" upon which it is based, and, as noted, the Veteran did not serve in the Republic of Vietnam or the Persian Gulf. Therefore, the opinion is afforded little, if any, probative value in this case. Thereafter, the Veteran underwent a VA headache examination in January 2014. He was diagnosed with tension headaches. The Veteran reported that he started having headaches while supervising cadets in a firing range instructor. He stated that he had been seeing providers over the years but was unsure of a diagnosis. The VA examiner reviewed the claims file and noted that the Veteran had not been seen for a chronic headache disorder while in service; that there were no medical records documenting a chronic headache disorder since discharge; and that his VA records did not document any visits from 2004 to 2014 where the Veteran complained of chronic headaches. The examiner also noted the absence of a headache diagnosis in the VA treatment records "problem list." The examiner stated that the Veteran's reported headache history was "not typical for migraine or tension headaches, but sound most consistent with tension headaches." In view of the above, the January 2014 VA examiner opined that it was less likely than not that his tension headache disorder was related to service, or to the headache experienced during service. In so finding, the examiner noted that the Veteran was seen once in service with a complaint of a headache and that that visit was also for stomach cramps and shoulder pain. The Veteran was not seen again for headache complaints while in-service based on the available medical records. He was also not seen for a chronic headache disorder based on private medical records until 2012, at which time his PCP stated the Veteran was suffering from chronic headaches, as well as other conditions - that was the first mention of headaches in his private or VA records and no formal diagnosis offered. In sum, the examiner stated that the Veteran was seen in service for a headache once. There was no recurrence and resolution of the headache was presumed based on the available records as there were no visits after this to suggest a chronic headache disorder in service. Additionally, there was no other documentation for over 20 years after discharge to suggest a chronic headache disorder. Therefore, the examiner concluded that the preponderance of evidence suggested "an acute, resolved headache while in service." The Board considers the opinion of the January 2014 examiner to be highly probative as to the issue of etiology/nexus as it was rendered after a thorough review of the Veteran's claims file and his medical history, and is consistent with other evidence of record, including STRs and post-service treatment records. It also contains a well-supported rationale. See, e.g., Prejean v. West, 13 Vet. App. 444 (2000). There are no probative medical opinions of record to the contrary. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a headache disorder. Indeed, while service treatment records show one documented complaint of a headache in 1969, there is no evidence that such resulted in a chronic headache disorder. Again, STRs are completely silent for recurrent complaints/treatment of headaches thereafter, and separation examination indicated a normal neurological clinical evaluation. This conclusion is entirely consistent with the VA examiner's highly probative opinion outlined above which found that the in-service headache was "acute" and "resolved." The earliest post-service reference to or diagnosis of any headache disability is dated in October 2012, over 41 years after the Veteran's discharge from his first period of active service, and nearly 21 years after discharge from his second period of active service. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (holding that the absence of treatment for the claimed disability for decades after service constituted negative evidence against the claim). This period without any complaints or treatment is evidence that weighs heavily against the claim herein. In so finding, the Board acknowledges that the Veteran's STRs from active service in 1991 and reserve service are unavailable for review; however, the Veteran has never asserted that he received or sought treatment for headaches during such periods of military service, and/or that headaches were aggravated therein. See Hearing Transcript. Moreover, the Veteran has been afforded multiple opportunities to submit medical evidence in his favor, including private medical evidence of treatment for headaches during this time period (i.e., subsequent to his 1971 separation from service, and prior to 2012), but has not done so. Also weighing against the claim is the highly probative opinion by the VA examiner in January 2014 finding that that the tension headache disorder was not related to service. Indeed, the Board finds the well-reasoned/supported VA opinion to be the most probative regarding the "nexus" element required to establish service connection, far outweighing the unsupported and speculative statement provided by Dr. D. To the extent the Veteran attributes his current headache disability to his military service, the Board acknowledges that he can attest to factual matters of which he had first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). While the Veteran's statements are competent evidence as to what he experienced or observed, his statements as to the etiology of his current headache disability is not competent evidence sufficient to provide a nexus between his current headache disorder and his military service. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Moreover, service connection on the basis of continuity of symptomatology can only be established for the chronic diseases as specified at 38 C.F.R. § 3.309(a), which does not include tension headaches. See Walker, supra. The Board also finds some discrepancies as to the Veteran's contentions regarding his history of ongoing headaches beginning in service. Again, on a medical history report, completed pursuant to his 1970 separation examination, the Veteran denied having any history of frequent or severe headaches. His service separation examination also noted normal neurological findings. Thereafter, the Veteran denied headaches in a 2010 VA treatment report, only to confirm a longstanding history of such upon VA examination in 2014. Such inconsistencies/discrepancies affect the overall credibility/probative value of the Veteran's statements concerning continuous headaches since service. See, e.g., Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996)(credibility can be generally evaluated by a showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony). Lastly, the Board recognizes the Veteran's lengthy service in the US Army Reserves, from 1971 to 1995; again, his treatment records (but not SPRs) are unavailable for this portion of his service. As noted, service connection may be granted for disability resulting from disease incurred in or aggravated while performing active duty for training ACDUTRA. In this case, however, none of the evidence outlined above, to include the Veteran's own lay statements, post-service VA and private treatment records, SPRs, and the highly probative VA medical assessment and accompanying opinion, even remotely suggests that his tension headache disorder was aggravated by a period of ACDUTRA. Again, the Veteran has consistently reported that his headaches had their onset during his first period of active duty service; he has made no assertions that such were aggravated by a subsequent period of ACDUTRA. In sum, as there is no probative medical evidence linking the Veteran's current headaches to any period(s) of his military service, service connection cannot be established. Hogan v. Peake, 544 F.3d 1295, 1297 (Fed. Cir. 2008). In reaching this decision, the Board has considered the doctrine of reasonable doubt, but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Low Back Disability The Veteran seeks service connection for a low back disability. During his hearing before the undersigned, he testified that he injured his back when he slipped and fell on ice while stationed at Fort Huachuca in 1969 or 1970. He has endorsed continuous low back symptomatology since that time. Again, STRs from the Veteran's brief period of active duty service in 1991, as well as STRs from his period of Reserve service (i.e., 1971 to 1995), have been sought, but are unavailable for review. See Formal Finding, September 2009; January 2014; see also PIES Responses, January 2008, and May 2013. The Board is aware of its heightened duty in this regard. See O'Hare, supra. As noted above, however, the Veteran primarily contends that his low back disability had its onset during his first period of active duty service, from 1969 to 1971. See Hearing Transcript. Service treatment records from the Veteran's first period of active duty service reveal a single complaint of low back pain and "other generalized complaints" in October 1969. No tenderness, spasms, or neurological abnormalities were noted. The Veteran was given aspirin. STRs contain no other findings related to the low back. The January 1970 separation examination is silent for complaints, treatment, or diagnoses relating to back problems; clinical evaluation of the spine was normal; and the Veteran denied a history of "back trouble of any kind" on his separation Report of Medical History. Following service, the first documented evidence of low back problems is not shown until 2008, at which time the Veteran presented to a private medical provider and was diagnosed with degenerative changes of the lumbar spine. Thereafter, VA and private treatment records document ongoing complaints of low back pain. In a 2010 VA treatment record, the Veteran reported having pain back since being in the military (noted as 20 years or more prior). In October 2012, Dr. D., a private physician, submitted a letter indicating that the Veteran had complained of chronic pain over various parts of his body, including back pain, and that he had mentioned he served during Vietnam and participated in Desert Storm. Dr. D stated then went on to state, "It's a possibility that his health problems may be caused by some type of exposure during his line of duty." Here, again, the Board notes that Dr. D's opinion is far too speculative to be of any significant probative value to establish a causal relationship. See Warren, and Obert, supra. Moreover, the opinion fails to identify the environmental "exposure" upon which it is based, and, as noted, the Veteran did not serve in the Republic of Vietnam or the Persian Gulf. Therefore, the opinion is afforded little, if any, probative value in this case. Thereafter, in January 2014, the Veteran was afforded a VA spine examination. At that time, the Veteran reported that he fell during Fire Watch down steps in the barracks in 1968. He stated that he fell on his back and was treated at sick call with pain relievers. He reported that he was seen while in service for this and he has experienced continued pain since that time. The pertinent diagnosis was lumbar arthritis. After review of the Veteran's claims file, the VA examiner opined that the low back disability was less likely than not related to service. In so finding, the examiner acknowledged that the Veteran was seen once on one occasion in-service in 1969 for low back pain. He had a normal exam and was treated conservatively at that time; here were no further visits for back pain in-service. Thereafter, the Veteran first presented to the Atlanta VAMC 2004 for care and there were no complaints of back pain on his initial visit. His first complaint was in 2010; he reported back pain at that time and stated that its onset was in-service. No films were done at that time but his private medical records show that Veteran had spondylosis on MRI in 2010. Based on the service treatment records, the examiner opined that there was no indication of a significant back injury while Veteran was on active duty. Additionally, the examiner opined that there was no evidence that the Veteran had a chronic back condition while in-service because "the back pain for which he was seen in service resolved based on available medical documentation." Additionally, the examiner noted that he had no profiles in the claims file for a back condition and private medical records did not show a diagnosis related to back pain until over 15 years after discharge from the reserves. The Veteran's age at the time of that diagnosis (61 years of age) was such that findings were most consistent with age-related degenerative changes. The Board considers the opinion of the January 2014 examiner to be highly probative as to the issue of etiology/nexus as it was rendered after a thorough review of the Veteran's claims file and his medical history, and is consistent with other evidence of record, including STRs/SPRs, and post-service treatment records. It also contains a well-supported rationale. See Prejean, supra. In so finding, the Board notes that the VA examiner stated that the record did not show complaints of back problems until 2010, when in fact, it was 2 years earlier in 2008 (see private treatment records). While this somewhat diminishes its probative value, it nevertheless remains the most probative medical opinion of record because the remaining rationale, taken as whole, is accurate and otherwise supported by the record. Indeed, based on his review of the STRs and the Veteran's treatment therein, the examiner explained that there was no indication of a significant back injury while on active duty and that the back condition for which he was treated in-service resolved; additionally, the current lumbar arthritis was consistent with the Veteran's age/age-related arthritis. This assessment is in agreement with the STRs and post-service treatment records. Notably, there are no probative medical opinions of record to the contrary. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a low back disability. Indeed, while service treatment records show a single, documented complaint of back pain in 1969, there is no evidence that such resulted in a chronic low back disability. Again, STRs are completely silent for recurrent complaints/treatment of back pain thereafter; separation examination indicated a normal clinical evaluation of the spine; and the Veteran denied back problems on his separation Report of Medical History. This conclusion is entirely consistent with the VA examiner's highly probative medical opinion outlined above which found that the isolated episode of low back pain in 1969 resolved with no further complaint until many years after service. In fact, the earliest post-service reference to or diagnosis of any low back disability is dated in 2008, nearly 37 years after the Veteran's discharge from his first period of active service, and 17 years after discharge from his second period of active service. See Maxson supra. This period without any complaints or treatment is evidence that weighs heavily against the claim herein. In so finding, the Board acknowledges that the Veteran's STRs from active service in 1991 and reserve service are unavailable for review; however, the Veteran has never asserted that he received or sought treatment for a low back disorder during such periods of military service, and/or that a back disorder was aggravated therein. See Hearing Transcript. Moreover, the Veteran has been afforded multiple opportunities to submit medical evidence in his favor, including private medical evidence of treatment for low back problems during this time period (i.e., subsequent to his 1971 separation from service, and prior to 2008), but has not done so. Also weighing against the claim is the highly probative opinion by the VA examiner in January 2014 finding that that the low back disability was not related to service. Indeed, the Board finds the well-reasoned/supported VA opinion to be the most probative regarding the "nexus" element required to establish service connection, far outweighing the unsupported and speculative statement provided by Dr. D. The Board also recognizes that the Veteran has been diagnosed with lumbar arthritis and that service connection via the demonstration of continuity of symptomatology is thus applicable in the present case. However, service connection is not warranted by virtue of application of 38 C.F.R. § 3.303(b), to the extent applicable, as the evidence fails to demonstrate the existence of a continuity of symptomatology. Nor can it be said that arthritis manifested within a year of separation from service as the first documented evidence of lumbar arthritis is not shown until 2008. (The one-year presumption for arthritis under 38 C.F.R. §§ 3.307, 3.309 is therefore not helpful.) In finding that service connection for arthritis of the lumbar spine is not warranted based on the lack of nexus evidence, the Board is cognizant of the fact that "[l]ay testimony is competent . . . to establish the presence of observable symptomatology and 'may provide sufficient support for a claim of service connection.'" Barr, 21 Vet. App. at 307 (quoting Layno v. Brown, 6 Vet. App. 465, 469 (1994)). Here, although the Veteran has asserted that he injured his low back in service in the 1960's and has had pain since that time, the service and post-service medical records weigh against such a finding. Thus, the Board finds that although the Veteran is competent to report on pain since his asserted in-service injury, the lack of evidence supporting that assertion preponderates against the claim that the Veteran has experienced a continuity of symptomatology since the alleged in-service injury. Rather, the evidence shows that the Veteran experienced a single episode of non-specific low back pain 1969, which resolved, and that back problems were not again shown until 2008, at which time lumbar arthritis (age-related arthritis, according to the January 2014 VA examiner) was diagnosed. Such evidence leads the Board to conclude that the Veteran's allegation of continuity of problems since the alleged in-service injury is not credible. Lastly, the Board recognizes the Veteran's lengthy service in the US Army Reserves, from 1971 to 1995; again, his treatment records (but not SPRs) are unavailable for this portion of his service. As noted, service connection may be granted for disability resulting from disease incurred in or aggravated while performing active duty for training ACDUTRA. In this case, however, none of the evidence outlined above, to include the Veteran's own lay statements, post-service VA and private treatment records, SPRs, and the highly probative VA medical assessment and accompanying opinion, even remotely suggests that his current low back disability was aggravated by a period of ACDUTRA. Again, the Veteran has consistently reported that his low back disability had its onset with injury during his first period of active duty service; he has made no assertions that such was aggravated by a subsequent period of ACDUTRA. In sum, as there is no probative medical evidence linking the Veteran's current low back disability to any period(s) of his military service, service connection cannot be established. Hogan, supra. In reaching this decision, the Board has considered the doctrine of reasonable doubt, but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. Gilbert, supra. 3. Gastrointestinal Disorder The Veteran seeks service connection for a gastrointestinal disability, claimed as gastritis. During his hearing before the undersigned, he testified that he was treated during his first period of active duty service for gastrointestinal complaints and that he has experienced near-continuous GI symptomatology since that time. Again, STRs from the Veteran's brief period of active duty service in 1991, as well as STRs from his period of Reserve service (i.e., 1971 to 1995), have been sought, but are unavailable for review. See Formal Finding, September 2009; January 2014; see also PIES Responses, January 2008, and May 2013. The Board recognizes its heightened duty in this regard. See O'Hare, supra. As noted above, however, the Veteran primarily contends that his gastrointestinal disability had its onset during his first period of active duty service, from 1969 to 1971. See Hearing Transcript. Service treatment records from the Veteran's first period of active duty service reveal complaints of severe stomach pain in 1969 and a diagnosis of gastroenteritis in January 1970. The December 1970 separation examination is silent for complaints, treatment, or diagnoses relating to stomach and/or gastrointestinal problems; clinical evaluation of the stomach was normal; and the Veteran denied a history of stomach trouble on his separation Report of Medical History. Following service, the first documented evidence of gastrointestinal/gastritis problems is not shown until 2004. See VA Treatment Records, Dated 2004 to 2010. Otherwise, a 2006 private treatment records documents a diagnosis of GERD, and an undated endoscopy report submitted in 2013 indicated a hiatal hernia. In October 2012, Dr. D., a private physician, submitted a letter indicating that the Veteran had complained of chronic pain over various parts of his body, including gastritis, and that he had mentioned he served during Vietnam and participated in Desert Storm. Dr. D stated then went on to state, "It's a possibility that his health problems may be caused by some type of exposure during his line of duty." Here, the Board again notes that Dr. D's opinion is far too speculative to be of any significant probative value to establish a causal relationship. See Warren; see also Obert, both supra. Moreover, the opinion fails to identify the environmental "exposure" upon which it is based, and, as noted, the Veteran did not serve in the Republic of Vietnam or the Persian Gulf. Therefore, the opinion is afforded little, if any, probative value in this case. Thereafter, in January 2014, the Veteran underwent a VA esophageal examination. Pertinent diagnoses included GERD and gastritis. The Veteran reported that he was treated for gastritis in basic training and that his symptoms never resolved. He reported that he had been treated with medication over the years and that an endoscopy in the past showed GERD. He endorsed stomach pain and gassiness chronically, and an inability to eat spicy or acidic foods. After review of the Veteran's claims file, to include STRs, post-service treatment, and SPRs, the VA examiner opined that the Veteran's gastrointestinal disorder was less likely than not related to service. In so finding, the examiner noted that the Veteran had presented on several occasions in service in 1969 with complaints of GI upset. At his first visit, the Veteran reported vomiting and chest pain related to the food he was eating. He was diagnosed with "functional symptoms" and given medications for such. He was seen again in February and reported his symptoms had not resolved with medications previously given. He also complained of headache and right shoulder pain. No definitive diagnosis was noted in record and Veteran was treated symptomatically again. The Veteran had one other visit for GI upset in 1970 and was diagnosed with gastroenteritis. The VA examiner noted that there was no indication that the Veteran had a chronic gastrointestinal disorder while in service; that there were no records of his care until the mid to late 2000s; and that his current symptoms "sound related to GERD and he is on therapy for such." This, the examiner stated, is presumably the "gastritis" that Veteran has claimed. The examiner also stated that he had reviewed the Veteran's Army Reserve records (personnel) records and that the Veteran was noted to have worked to work in food services while in-service and had no limitations related to claimed GI disease. Further, the Veteran's visit to the VA in 2004 did not mention a GI disorder or complaint and in addition, and there were no private medical records indicating a gastrointestinal complaint until 2006. The examiner stated that this "was a full 15 years after Veteran's discharge from the reserves and would be too remote to allow an assumption of a service incurred disability." Additionally, Veteran's GI complaints in service were temporal and resolved based on his not presenting repeatedly for GI upset. Rather, his symptoms during service were most consistent with acute disease and would not be expected to be persistent for decades. Finally, the EGD report did not have a date, but it is notable that there was no diagnosis of gastritis included amongst the findings on that exam. (See GI DBQ for full description of findings.). In sum, the VA examiner stated that it was less likely than not that GERD was incurred in or caused by his claimed in-service gastritis. The Board considers the opinion of the January 2014 examiner to be highly probative as to the issue of etiology/nexus as it was rendered after a thorough review of the Veteran's claims file and his medical history, and is consistent with other evidence of record, including STRs/SPRs, and post-service treatment records. It also contains a well-supported rationale. See Prejean, supra. In so finding, the Board notes that the VA examiner stated that the record did not show complaints of GI problems until 2006, when in fact, it was 2 years earlier in 2004 (see VA treatment records). While this somewhat diminishes its probative value, it nevertheless remains the most probative medical opinion of record because the remaining rationale, taken as whole, is accurate and otherwise supported by the record. Indeed, based on his review of the STRs and the Veteran's treatment therein, the examiner explained that the GI issues in-service were temporal and not chronic, and that there were no complaints for such until the mid-2000's. This assessment is in agreement with the STRs and post-service treatment records. Notably, there are no probative medical opinions of record to the contrary. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a gastrointestinal disorder. Indeed, while service treatment records show several documented GI complaints in 1969/1970, there is no evidence that such resulted in a chronic gastrointestinal disorder. Again, STRs are completely silent for recurrent complaints/treatment of GI problems after the 1970 gastroenteritis episode, separation examination indicated a normal clinical evaluation of the stomach, and the Veteran denied a history of stomach problems on his separation Report of Medical History. This conclusion is entirely consistent with the VA examiner's highly probative opinion outlined above which found that the in-service GI episodes were temporal and not chronic in nature. The earliest post-service reference to or diagnosis of any GI disability is dated in 2004, over 33 years after the Veteran's discharge from his first period of active service, and nearly 13 years after discharge from his second period of active service. This period without any complaints or treatment is evidence that weighs heavily against the claim herein. See Maxson, supra. In so finding, the Board acknowledges that the Veteran's STRs from active service in 1991 and reserve service are unavailable for review; however, the Veteran has never expressly asserted that he received or sought treatment for gastritis during such periods of military service, and/or that gastritis was aggravated therein. See Hearing Transcript. Moreover, the Veteran has been afforded multiple opportunities to submit medical evidence in his favor, including private medical evidence of treatment for GI problems during this time period (i.e., subsequent to his 1971 separation from service, and prior to 2004), but has not done so. Also weighing against the claim is the highly probative opinion by the VA examiner in January 2014 finding that that the currently diagnosed GI disorders are not related to service. Indeed, the Board finds the well-reasoned/supported VA opinion note above to be the most probative regarding the "nexus" element required to establish service connection, far outweighing the unsupported and speculative statement provided by Dr. D. To the extent the Veteran attributes his current GI disability to his first period of military service, the Board acknowledges that he can attest to factual matters of which he had first-hand knowledge. See Washington, supra. While the Veteran's statements are competent evidence as to what he experienced or observed, his statements as to the etiology of his current GI disability are not competent evidence sufficient to provide a nexus between his current GI disorder and his military service. Jandreau, supra. Moreover, service connection on the basis of continuity of symptomatology can only be established for the chronic diseases as specified at 38 C.F.R. § 3.309(a), which does not include gastritis or GERD. See Walker, supra. Lastly, the Board recognizes the Veteran's lengthy service in the US Army Reserves, from 1971 to 1995; again, his treatment records (but not SPRs) are unavailable for this portion of his service. As noted, service connection may be granted for disability resulting from disease incurred in or aggravated while performing active duty for training ACDUTRA. In this case, however, none of the evidence outlined above, to include the Veteran's own lay statements, post-service VA and private treatment records, SPRs, and the highly probative VA medical assessment and accompanying opinion, even remotely suggests that his GI disorder was aggravated by a period of ACDUTRA. Again, the Veteran has consistently reported that his GI disorder had its onset during his first period of active duty service; he has made no assertions that such was aggravated by a subsequent period of ACDUTRA. In sum, as there is no probative medical evidence linking the Veteran's current GI disorders to any period(s) of his military service, service connection cannot be established. Hogan, supra. In reaching this decision, the Board has considered the doctrine of reasonable doubt, but has determined that it is not applicable to this claim because the preponderance of the evidence is against the claim. Gilbert supra. 4. Carpal Tunnel Syndrome (CTS) The Veteran seeks service connection for carpal tunnel syndrome. During his hearing before the undersigned, he testified that he was first treated in-service (i.e., his second period of active service in 1991) for CTS, and that he was given a nerve conduction study at that time which revealed mild CTS/or paralysis. The Veteran reported that he continues to receive treatment through VA. Service treatment records from the Veteran's first period of active duty service are entirely silent as to complaints, treatment, or diagnoses of carpal tunnel syndrome, and/or wrist problems. The December 1970 separation examination noted a normal clinical evaluation of the upper extremities and neurological system, and the Veteran denied a history of neuritis, paralysis, swollen/painful joints on his separation Report of Medical History. Again, STRs from the Veteran's brief period of active duty service in 1991, as well as STRs from his period of Reserve service (i.e., 1971 to 1995), have been sought, but are unavailable for review. See Formal Finding, September 2009; January 2014; see also PIES Responses, January 2008, and May 2013. The Board is aware of its heightened duty in this regard. See O'Hare, supra. The first documented evidence of CTS is not shown until 2004. See VA Treatment Records. At that time, the Veteran reported that he had tests a "long time ago" in NY hospital outside VA and was told he had carpal tunnel syndrome. In 2010 VA treatment records, he again complained of CTS and reported an onset date of 1994. In October 2012, Dr. D., a private physician, submitted a letter indicating that the Veteran had complained of chronic pain over various parts of his body, including carpal tunnel syndrome, and that he had mentioned he served during Vietnam and participated in Desert Storm. Dr. D stated then went on to state, "It's a possibility that his health problems may be caused by some type of exposure during his line of duty." Here, the Board again notes that Dr. D's opinion is far too speculative to be of any significant probative value to establish a causal relationship. See Warren; see also Obert, both supra. Moreover, the opinion fails to identify the environmental "exposure" upon which it is based, and, as noted, the Veteran did not serve in the Republic of Vietnam or the Persian Gulf. Therefore, the opinion is afforded little, if any, probative value in this case Thereafter, in January 2014, the Veteran underwent a VA peripheral nerves examination; the diagnosis provided was bilateral carpal tunnel syndrome. At that time, the Veteran reported that he was diagnosed with carpal tunnel in 1991, upon his return from Desert Storm. After reviewing of the Veteran's claims file, the January 2014 VA examiner provided an opinion that the currently diagnosed CTS was less likely than not related to service. In so finding, the examiner noted that, despite the Veteran's reports of a 1994 onset, the earliest records with this complaint were from March 2010 when a VA EMG confirmed diagnosis of bilateral carpal tunnel syndrome. The examiner thus stated that while the Veteran contends that his carpal tunnel syndrome began soon after serving in 1991, there are no service treatment records showing treatment while in-service for wrist discomfort or paresthesias of the hands. Moreover, his personnel records showed a profile for hypertension and hyperlipidemia in January or June of 1991, but no other profiles were noted. The Veteran also worked in food services, but none of his personnel evaluations mentioned of his having difficulty performing duties due to carpal tunnel disease or otherwise. In essence, the examiner found that there were no records showing that Veteran complained of wrist pain or was diagnosed with carpal tunnel syndrome while on active duty. Additionally, the examiner stated, while the repetitive motions associated with food preparation could possibly increase the risk of carpal tunnel syndrome, the Veteran's limited time spent on active duty made this risk negligible. The Board considers the opinion of the January 2014 examiner to be highly probative as to the issue of etiology/nexus as it was rendered after a thorough review of the Veteran's claims file and his medical history, and is consistent with other evidence of record, including STRs, SPRs, and post-service treatment records. It also contains a well-supported rationale. See Prejean, supra. Notably, there are no probative medical opinions of record to the contrary. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for carpal tunnel syndrome. Again, the Veteran essentially maintains that his CTS disorder had its onset during active duty service in 1991. In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court, citing Layno v. Brown, 6 Vet. App. 465, 467-69 (1994), emphasized that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge. See also 38 C.F.R. § 3.159(a)(2). The Veteran's available service personnel records show that he worked in food service (i.e., with his hands); he has consistently stated that he was given a nerve conduction study test based on reported symptoms in-service in 1991, which confirmed CTS. As such, although the Veteran's STRs for his second period of service are not of record, the Veteran's account of in-service symptomatology is considered competent. Having found the Veteran's lay statements to be competent, the Board must also determine whether such evidence is credible. See Layno, supra. In weighing the credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the appellant. Caluza, supra. Further, the Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 Vet. App. 1331 (Fed. Cir. 2006). The Board finds the Veteran's account of in-service CTS symptomatology to be credible in light of the evidence of record. Specifically, the Veteran's post-military medical records include his reports of experiencing CTS symptomatology for "a long time" with an onset in the 1990's. The Board points out that this reported history was given in connection with the Veteran seeking initial medical treatment in 2004 and preceded the Veteran's claim for service connection benefits. Thus, his report is highly probative and exceptionally trustworthy. See Rucker v. Brown, 10 Vet. App. 67 (1997) (holding that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Moreover, there is no evidence of record that contradicts the Veteran's assertions of in-service symptomatology. Caluza. Thus, this lay statement corroborates the Veteran's assertion that he experienced CTS symptoms during his period of active service in 1991. However, the fact remains that the preponderance of the evidence does not show that the Veteran suffered a chronic injury or disability as a result of the claimed in-service incident. While the Veteran's account of in-service CTS symptomatology is credible, there is no competent medical evidence that suggests a nexus between the Veteran's currently diagnosed CTS and his second period of active service. As noted, the Board finds the well-reasoned/supported VA opinion to be the most probative regarding the "nexus" element required to establish service connection, far outweighing the unsupported and speculative statement provided by Dr. D., and the lay statements provided by the Veteran (see below). The Veteran has not provided any competent medical evidence to rebut the opinion against his claim or otherwise diminish its probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). The Board notes that the medical evidence does not show a diagnosis of CTS until 2004, nearly a decade following the Veteran's separation from active service in 1991. Thus, while the Veteran has reported having CTS symptoms since his military service in 1991, and the lay statements include reports of ongoing CTS problems, there is no objective evidence of continuity of symptomatology to suggest that he has CTS related to his second period of active service. See Maxson, supra. Moreover, service connection on the basis of continuity of symptomatology can only be established for the chronic diseases as specified at 38 C.F.R. § 3.309(a), which does not include carpal tunnel syndrome. See Walker, supra In reaching the above determination, the Board again notes that consideration has been given to the Veteran's statements that his current carpal tunnel condition is related to his military service. Lay statements may be competent to support a claim for service connection where the events or the presence of disability or symptoms of a disability are subject to lay observation. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a), 3.159(a); Jandreau, Buchanan, both supra. However, a CTS is not a disability subject to lay opinions as to diagnosis and etiology. While some symptoms of the disorders, such as pain/paralysis/numbness, may be reported by a layperson, the diagnosis and etiology of the disorders require medical training. The Veteran does not have the medical expertise to diagnose himself with CTS, nor does he have the medical expertise to provide an opinion regarding its etiology. Thus, the Veteran's lay assertions as to the etiology of his CTS diagnosis are not competent or sufficient in this instance. Jandreau, 492 F.3d 1372. Lastly, the Board recognizes the Veteran's lengthy service in the US Army Reserves, from 1971 to 1995; again, his treatment records (but not SPRs) are unavailable for this portion of his service. As noted, service connection may be granted for disability resulting from disease incurred in or aggravated while performing active duty for training ACDUTRA. In this case, however, none of the evidence outlined above, to include the Veteran's own lay statements, post-service VA and private treatment records, SPRs, and the highly probative VA medical assessment and accompanying opinion, even remotely suggests that his CTS was aggravated by a period of ACDUTRA. In fact, the Veteran has consistently reported that his CTS disorder had its onset during his second period of active duty service in 1991; he has made no assertions that such was aggravated by a subsequent period of ACDUTRA. Given that the preponderance of the evidence weighs against the claim for CTS, for the Board to conclude that the Veteran has carpal tunnel syndrome that was incurred during his military service would be speculation, and the law provides that service connection may not be based on a resort to speculation or remote possibility. 38 C.F.R. § 3.102; Obert v. Brown, 5 Vet. App. 30, 33 (1993). Thus, the claim for service connection must be denied. In so concluding, the Board is cognizant of its responsibilities in cases in which records in the custody of the government are allegedly missing. See O'Hare, 1 Vet. App. at 367. The Board's analysis as to CTS was undertaken with this heightened duty in mind. The case law does not, however, lower the legal standard for proving a claim for service connection but rather increases the Board's obligation to evaluate and discuss in its decision all of the evidence that may be favorable to the appellant. See Russo v. Brown, 9 Vet. App. 46 (1996). In this case, the Board has no reason to doubt, and indeed accepts as true the Veteran's statements that he suffered CTS symptoms during service. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). However, as stated above, there continues to be no medical opinion relating the Veteran's current CTS diagnosis to his period of active service. Thus, even if the Veteran's assertions of in-service symptomatology are true, the assertions do not substantiate his claim for service connection for carpal tunnel syndrome in accordance with VA regulations. Essentially, as the weight of the competent and probative evidence is against a finding that the Veteran's claimed carpal tunnel syndrome is related to service, the preponderance of the evidence is against the service connection claim. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. See generally Gilbert, supra. The benefit sought on appeal is therefore denied. ORDER Entitlement to service connection for headaches is denied. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for gastritis is denied. Entitlement to service connection for carpal tunnel syndrome is denied. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs